Basic Information
Provider Information | |||||||||
NPI: | 1285802868 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SAULT TRIBE OF CHIPPEWA INDIANS | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2864 ASHMUN ST | ||||||||
Address2: |   | ||||||||
City: | SAULT SAINTE MARIE | ||||||||
State: | MI | ||||||||
PostalCode: | 497833740 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9066325200 | ||||||||
FaxNumber: | 9066325276 | ||||||||
Practice Location | |||||||||
Address1: | 2864 ASHMUN ST | ||||||||
Address2: |   | ||||||||
City: | SAULT SAINTE MARIE | ||||||||
State: | MI | ||||||||
PostalCode: | 497833740 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9066325200 | ||||||||
FaxNumber: | 9066325276 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/15/2008 | ||||||||
LastUpdateDate: | 05/30/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CULFA | ||||||||
AuthorizedOfficialFirstName: | BONNIE | ||||||||
AuthorizedOfficialMiddleName: | L | ||||||||
AuthorizedOfficialTitleorPosition: | DIVISION OF HEALTH DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 9066325200 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) | 1223G0001X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
ID Information
ID | Type | State | Issuer | Description | J802165 | 01 | MI | BC/BS OF MI | OTHER |